Nutrition in medical education in Latin America: Results of a cross-sectional survey.

RATIONALE: The gap between the nutrition education provided to medical students and the nutrition competences and attitudes needed for doctors to provide effective nutrition care is a global concern. The goal of this study was to investigate the curricular content on nutrition education in Latin American medical schools and to evaluate the self-perceived knowledge, attitudes, and barriers to nutrition practice of final-year medical students. METHODS: Eighty-five public and private medical schools from 17 Latin American countries were invited to participate in the study. Two close-ended online questionnaires consisting of 25 and 43 questions were sent to medical school directors. Quantitative variables were expressed as frequencies, percentages, mean ± standard deviation, medians, and ranges. RESULTS: A total of 22 (26%) medical school directors responded, of which 11 schools (50%) offered stand-alone mandatory nutrition courses in preclinical and 8 (36%) in clinical years. The mean hours dedicated to nutrition education was 47 (range: 0-150). A total of 1530 of 1630 (94%) students from 12 countries responded. Students' average age was 25 ± 3 years, and 59% were female. Most students agreed that improving patients' health through nutrition (91%) is important and that nutrition counseling and assessment should be part of routine care provided by all physicians (89%), but they lack the level of education and training required to address nutrition-related issues. CONCLUSIONS: Positive attitude and interest in nutrition among final-year medical students is high, but nutrition education is not perceived as sufficient to adequately prepare doctors in the field of nutrition.

May Measurement Month 2019: an analysis of blood pressure screening results from Ecuador.

Arterial hypertension is a growing burden worldwide, leading to over 10.8 million deaths each year. In Ecuador, it is the main risk factor for the major cause of death, coronary, and cerebrovascular disease [GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioral, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1923-1994]. The May Measurement Month Campaign in 2019 (MMM19) is a global initiative of the International Society of Hypertension aimed at raising awareness of high blood pressure (BP) and to act as a temporary solution to the lack of screening programs worldwide. A volunteer cross-sectional survey was carried out in May 2019 across 42 health centres in Ecuador. The average age was 51 (SD ±17.6) years. Blood pressure measurement, the definition of hypertension (mean of the second and third BP measurement ≥140/90 mmHg or who were medicated for high BP), and statistical analysis followed the standard MMM protocol. In total, 15 885 volunteers participated in MMM19. After multiple imputation, 6654 (41.9%) had hypertension. Of individuals not receiving antihypertensive medication, 2383 (20.5%) were hypertensive. Of individuals receiving antihypertensive medication, 1004 (23.5%) had uncontrolled BP. May Measurement Month 2019 was the largest BP screening campaign done in Ecuador. In the survey, including 6654 participants with hypertension, only 49.1% had their BP values controlled (<140/90 mmHg). May Measurement Month 2019 demonstrated a high prevalence of hypertension among volunteer screenees in our country. The high percentage of persons untreated or with uncontrolled hypertension while on pharmacologic treatment suggest that appropriate screening can help to identify a significant number of people with high BP. These data should attract the attention of health care providers and the healthcare system in Ecuador.

May Measurement Month 2018: an analysis of blood pressure screening results from Ecuador.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative by the International Society of Hypertension (ISH) aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2018. A volunteer cross-sectional survey was carried out in May 2017 across 33 health centres. Blood pressure measurement, the definition of hypertension (HTN) (mean of the 2nd and 3rd BP measurement ≥ 140/90 mmHg or who were medicated for high BP), and statistical analysis followed the standard MMM protocol. In total, 11 922 individuals (53.7% female) were screened during MMM18. After multiple imputation, 4563 (38.3%) had HTN. Of individuals not receiving antihypertensive medication, 1302 (15.0%) were hypertensive. Of individuals receiving antihypertensive medication, 933 (28.6%) had uncontrolled BP. MMM18 was the largest BP screening campaign done in Ecuador. Hypertension was detected in 38.4% of those screened and almost 4 out of 10 were either not on treatment or were not controlled to the BP goal. These results suggest that appropriate screening can help to identify a significant number of people with high BP. These data should attract the attention of doctors and health care system in Ecuador.

Treatment Eligibility and Therapeutic Responses of an Ecuadorian Population at High Cardiovascular Risk Based on the ATP III Guidelines

Abstract Background The Adult Treatment Panel III (ATPIII) guidelines aim to reduce cardiovascular morbidity and mortality. In Ecuador, 20% of people have high LDL cholesterol levels, and 39% have high triglyceride levels. Objective To analyze lipid-lowering regimens in Ecuadorian patients and determine the achievement rate of the ATPIII goals for lipid profile. Methods Using a retrospective analysis, 385 subjects older than 30 years, who received pharmacological treatment for dyslipidemia for at least three months was randomly selected from institutions at two large cities in Ecuador. Data were collected from patients' medical records and analyzed by chi-square test or paired t-test; p-values less than 0.05 were considered significant. Results Baseline total cholesterol values were above 200 mg/dL in 75% of subjects, LDL-c values above 129 mg/dL in 83% of subjects and triglycerides values above 150 mg/dL in 79% of subjects. Most (n = 253, 95.8%) patients at very high cardiovascular risk were taking statins, 50% of them atorvastatin. Considering the ATPIII guidelines' goals, only 24 subjects (19%) at high CV risk achieved an LDL-c < 100 mg/dl, while a significantly lower percentage (p = 0.04) of patients at very high risk reached an LDL-c < 70mg/dl (11%; n = 30). Conclusion These data indicate a low rate of compliance with the ATPIII guidelines, independent of the medication used or duration of the treatment. This may be attributed to the prescription of low doses of medication and a therapy targeting isolated lipid fractions rather than a complete lipid profile. (Int J Cardiovasc Sci. 2020; 33(4):371-376)

May Measurement Month 2017: analysis of the blood pressure screening results in Ecuador-Americas.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. Previous hypertension surveys in Ecuador, showed that there was a prevalence of 28% of adults with hypertension in 1999, 53% in adults between 60 and 75 years in 2010, and. 9.3% in people between 18 and 59 years in 2012 [Freire WB, Ramírez-Luzuriaga MJ, Belmont P, Mendieta MJ, Silva-Jaramillo MK, Romero N, Sáenz K, Piñeiros P, Gómez LF, Monge R. Tomo I: Encuesta Nacional de Salud y Nutrición de la población ecuatoriana de cero a 59 años. ENSANUT-ECU 2012. Ministerio de Salud Pública/Instituto Nacional de Estadísticas y Censos. Quito-Ecuador 2014]. The May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP that can temporarily address the lack of screening programmes worldwide. Verbal informed consent was obtained from respondents. We enrolled 16 sites for the measurement of arterial BP and completion of the MMM17 questionnaire, the most important sites being: Guayaquil, Quito, Cuenca, Milagro, Esmeraldas, Duran, Naranjito, and Machala. We administered the MMM17 survey on 6984 people, of which 50.5% of them were men and 48.4% were women. Mean age was 46.62 ± 17.71 SD. The crude mean BP was 115/74 mmHg. Of the 6984 people who completed the survey, we had 1522 that were already taking anti-hypertensive treatment. The number of people with hypertension (≥140 or ≥90 or on treatment for hypertension) was 1968/6982 (28.2%) persons. The number of people with hypertension of those not receiving treatment was 446/5460 (8.2%) and the number of people receiving treatment but with controlled and uncontrolled BP was 1136/1522 (74.6%) and 386/1522 (25.4%), respectively. MMM17 was the largest BP screening campaign undertaken in Ecuador. We identified 446 people with hypertension that were not receiving any treatment and 386 people with uncontrolled hypertension. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Peripheral Blood MCEMP1 Gene Expression as a Biomarker for Stroke Prognosis.

BACKGROUND AND PURPOSE: A limitation when making early decisions on stroke management is the lack of rapid diagnostic and prognostic testing. Our study sought to identify peripheral blood RNA biomarkers associated with stroke. The secondary aims were to assess the discriminative capacity of RNA biomarkers for primary stroke type and stroke prognosis at 1-month. METHODS: Whole-blood gene expression profiling was conducted on the discovery cohort: 129 first-time stroke cases that had blood sampling within 5 days of symptom onset and 170 control participants with no history of stroke. RESULTS: Through multiple regression analysis, we determined that expression of the gene MCEMP1 had the strongest association with stroke of 11 181 genes tested. MCEMP1 increased by 2.4-fold in stroke when compared with controls (95% confidence interval, 2.0-2.8; P=8.2×10(-22)). In addition, expression was elevated in intracerebral hemorrhage when compared with ischemic stroke cases (P=3.9×10(-4)). MCEMP1 was also highest soon after symptom onset and had no association with stroke risk factors. Furthermore, MCEMP1 expression independently improved discrimination of 1-month outcome. Indeed, discrimination models for disability and mortality that included MCEMP1 expression, baseline modified Rankin Scale score, and primary stroke type improved discrimination when compared with a model without MCEMP1 (disability Net Reclassification Index, 0.76; P=3.0×10(-6) and mortality Net Reclassification Index, 1.3; P=1.1×10(-9)). Significant associations with MCEMP1 were confirmed in an independent validation cohort of 28 stroke cases and 34 controls. CONCLUSIONS: This study demonstrates that peripheral blood expression of MCEMP1 may have utility for stroke diagnosis and as a prognostic biomarker of stroke outcome at 1-month.

Hiperglucemia se asocia a mayor número de desenlaces adversos en individuos latinoamericanos con infarto agudo de miocardio / Hyperglycaemia is associated with worse outcomes in Latin-American individuals with acute myocardial infarction

Introducción: Las alteraciones en el metabolismo de la glucosa son un factor de riesgo y de peor pronóstico para infarto agudo de miocardio (IAM), pero esta información en población latinoamericana es limitada. Por tanto, evaluamos la asociación del estado glucémico con desenlaces a corto y largo plazo en pacientes con un primer IAM. Métodos: Estudio observacional de cohorte, multicéntrico, prospectivo, conducido en 8 hospitales de Colombia y Ecuador. Resultados: Se incluyeron en total 439 pacientes con diagnóstico confirmado de IAM, de los cuales 305 (69,5%) presentaron prediabetes o diabetes mellitus tipo 2 (DM2). En comparación con el grupo de normoglucemia, los pacientes con DM2 conocida presentaron mayor riesgo de estancia hospitalaria prolongada (HR: 2,60, IC 95%: 1,38-4,92, p = 0,003), de Killip clase iii/iv (HR: 9,46, IC 95%: 2,20-40,62, p = 0,002) y de insuficiencia cardiaca intrahospitalaria (HR: 10,76, IC 95%: 3,37-34,31, p < 0,001). Los pacientes con prediabetes, DM2 conocida y DM2 nueva tuvieron tasas más altas de episodios adversos cardiovasculares mayores en el seguimiento a 3 años. Conclusión: Alteraciones en el metabolismo de la glucosa tienen una importante significación pronóstica a corto y a largo plazo en pacientes latinoamericanos sobrevivientes a un primer IAM

Background: Alterations in glucose metabolism have been reported as risk and poor prognostic factors for acute myocardial infarction (AMI); however in Latin-American population this information is limited. Thus, an evaluation was performed on the association between glycaemic status and short- and long-term outcomes in patients with a first AMI. Methods: A multicentre, prospective, observational, cohort study was conducted in 8 hospitals from Colombia and Ecuador. Results: A total of 439 patients with confirmed AMI were included, of which 305 (69.5%) had prediabetes or type 2 diabetes mellitus (DM2). Compared with normal glycaemia group, patients with known DM2 had greater risk of prolonged hospital stay (HR: 2.60, 95% CI: 1.38-4.92, P = .003), Killip class iii/iv (HR: 9.46, 95% CI: 2.20-40.62, P = .002), and in-hospital heart failure (HR: 10.76, 95% CI: 3.37-34.31, P < .001). Patients with prediabetes, new DM2, and known DM2 showed higher rates of major adverse cardiovascular events after 3 years follow-up. Conclusion: Glucose metabolism abnormalities have an important significance in the short- and long-term prognosis in Latin-American patients that survive a first AMI

[Hyperglycaemia is associated with worse outcomes in Latin-American individuals with acute myocardial infarction]. / Hiperglucemia se asocia a mayor número de desenlaces adversos en individuos latinoamericanos con infarto agudo de miocardio.

BACKGROUND: Alterations in glucose metabolism have been reported as risk and poor prognostic factors for acute myocardial infarction (AMI); however in Latin-American population this information is limited. Thus, an evaluation was performed on the association between glycaemic status and short- and long-term outcomes in patients with a first AMI. METHODS: A multicentre, prospective, observational, cohort study was conducted in 8 hospitals from Colombia and Ecuador. RESULTS: A total of 439 patients with confirmed AMI were included, of which 305 (69.5%) had prediabetes or type2 diabetes mellitus (DM2). Compared with normal glycaemia group, patients with known DM2 had greater risk of prolonged hospital stay (HR: 2.60, 95%CI: 1.38-4.92, P=.003), Killip class iii/iv (HR: 9.46, 95%CI: 2.20-40.62, P=.002), and in-hospital heart failure (HR: 10.76, 95%CI: 3.37-34.31, P<.001). Patients with prediabetes, new DM2, and known DM2 showed higher rates of major adverse cardiovascular events after 3years follow-up. CONCLUSION: Glucose metabolism abnormalities have an important significance in the short- and long-term prognosis in Latin-American patients that survive a first AMI.

Angiotensin receptor neprilysin inhibition compared with enalapril on the risk of clinical progression in surviving patients with heart failure.

BACKGROUND: Clinical trials in heart failure have focused on the improvement in symptoms or decreases in the risk of death and other cardiovascular events. Little is known about the effect of drugs on the risk of clinical deterioration in surviving patients. METHODS AND RESULTS: We compared the angiotensin-neprilysin inhibitor LCZ696 (400 mg daily) with the angiotensin-converting enzyme inhibitor enalapril (20 mg daily) in 8399 patients with heart failure and reduced ejection fraction in a double-blind trial. The analyses focused on prespecified measures of nonfatal clinical deterioration. In comparison with the enalapril group, fewer LCZ696-treated patients required intensification of medical treatment for heart failure (520 versus 604; hazard ratio, 0.84; 95% confidence interval, 0.74-0.94; P=0.003) or an emergency department visit for worsening heart failure (hazard ratio, 0.66; 95% confidence interval, 0.52-0.85; P=0.001). The patients in the LCZ696 group had 23% fewer hospitalizations for worsening heart failure (851 versus 1079; P<0.001) and were less likely to require intensive care (768 versus 879; 18% rate reduction, P=0.005), to receive intravenous positive inotropic agents (31% risk reduction, P<0.001), and to have implantation of a heart failure device or cardiac transplantation (22% risk reduction, P=0.07). The reduction in heart failure hospitalization with LCZ696 was evident within the first 30 days after randomization. Worsening of symptom scores in surviving patients was consistently more common in the enalapril group. LCZ696 led to an early and sustained reduction in biomarkers of myocardial wall stress and injury (N-terminal pro-B-type natriuretic peptide and troponin) versus enalapril. CONCLUSIONS: Angiotensin-neprilysin inhibition prevents the clinical progression of surviving patients with heart failure more effectively than angiotensin-converting enzyme inhibition. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.

Comparación de la eficiencia entre el carvedilol y bisoprolol en el manejo de 60 pacientes con insuficiencia cardíaca, hospital Luis Vernaza, controlados desde el 2002 – 2007 / Efficiency comparison between carvedilol and bisoprolol in the treatment of 60 patients with heart failure, Luis Vernaza hospital, controlled from 2002 to 2007

Tipo de Estudio: clínico, comparativo, longitudinal, tipo prospectivo de dos ramas, que se llevó a cabo en la consulta externa del hospital “Luís Vernaza”, de Guayaquil. El universo del estudio constituyó todos los pacientes que ingresaron a la consulta con el diagnóstico de insuficiencia cardíaca congestiva de origen isquémico y no isquémico durante el período comprendido desde junio de 2002 a diciembre de 2007. Objetivos: el principal es demostrar que los betabloqueantes, carvedilol y bisoprolol son igual de eficientes al reducir el riesgo de la progresión de la enfermedad basándonos en la mejoría de los parámetros ecocardiográficos y la clase funcional de los pacientes. Resultados: se reclutaron 60 pacientes con insuficiencia cardíaca de base etiológica isquémica (68,3) y no isquémica (31,7), la edad promedio fue 68,35 (SD 6,089) predominando el género femenino en 56,7. Se encontró mejoría en la FE con un aumento de 36,9 a 42,4 en el grupo de carvedilol y asimismo para el bisoprolol con 33,9 al 43,4 (p=0,083). En cuanto al DDVI en el grupo de carvedilol se reportó un ligero aumento de 57 a 57,5mm en comparación al grupo de bisoprolol donde hubo mejoría al disminuir de 58,8 a 56,8 mm sin mostrar diferencia significativa entre ambos betabloqueantes (p=0,156). El DSVI en ambos grupos tanto para el carvedilol y bisoprolol se lograron reducciones de 45 a 44,4mm y de 47,2 a 44,5mm respectivamente sin mostrar tampoco diferencia estadística (p=0,188). En cuanto al grado funcional los pacientes que previo al tratamiento ingresaron con CF III en 51,9 mejorando a la CF I en 63,5 Conclusiones: el estudio demuestra que ambos betabloqueantes tanto el carvedilol y bisoprolol son igual de eficientes como parte del tratamiento en pacientes con insuficiencia cardíaca congestiva al momento de disminuir el riesgo de progresión de la enfermedad ya que demostró mejoría en sus parámetros ecocardiográficos y en su grado funcional.

Study type: Clinical, comparative, longitudinal, prospective type of two branches that was carried out in outpatient consultation at “Luis Vernaza” hospital of Guayaquil. The crowd for the study were all the patients who entered to the consultation with the congestive heart failure diagnosis of ischemic and non-ischemic origin from June 2002 to December 2007. Objective: The main one is to demonstrate that beta blockers, carvedilol and bisoprolol are both efficient when progression risk is reduced based in the improvement of echocardiography parameters and the functional class of patients. Results: 60 patients with heart failure of etiological ischemic base (68.3) and non-ischemic base (31,7) were recruited, the average age was 68,35 (SD 6,089) predominating the female gender in 56,7. Improvement was evidenced in the FE “Fracción de Eyección” (Ejection Fraction) with an increase of 36,9 to 42,4 in the carvedilol group and likewise for bisoprolol with 33,9 to 43,4 (p=0,083). In terms of DDVI “Diámetro Diastólico del Ventrículo Izquierdo” (Left Ventricle Diastolic Diameter), in the carvidol group a slight increase of 57 to 57,5 mm was reported compared to bisoprolol group where there was improvement when diminishing from 58,8 to 56,8 mm without showing significant difference between both beta blockers (p=0,156). Reductions from 45 to 44,4.and from 47,2 to 44,5mm were also obtained in both groups carvedilol and bisoprolol The DSVI “Diametro Sistolico del Ventriculo Izquierdo” (Left Ventricle Sistolic Diameter, but without showing statistic difference either (p=0,188). As far as the functional rank is concerned, patients who previous to the treatment entered with CF III (Cystic Fibrosis III) in 51,9 improved to the CF I in 63,5.

Hipertensión arterial: respuesta inadecuada al tratamiento médico vs. paciente / Hypertension: inadequate response to the treatment physician vs. patient

Objetivo: Determinar las causas más comunes de una respuesta inadecuada al tratamiento antihipertensivo en nuestro medio, y qué porcentaje de la población hipertensa controla su presión con el tratamiento aplicado.Diseño del estudio: El presente es un estudio retroprospectivo, analítico, llevado a cabo en el Servicio de cardiología de la Consulta Externa del hospital Luis Vernaza de Guayaquil. La muestra fue de 100 pacientes hipertensos tratados en quienes se trató de determinar la eficacia del tratamiento antihipertensivo. De estos pacientes, a 30 no controlados se les realizó una encuesta para establecer la causa de su respuesta inadecuada al tratamiento.Resultados: Aproximadamente 60% de pacientes presentó un control eficaz de su presión arterial. Dentro de los no controlados se observó que la causa principal de la respuesta inadecuada al tratamiento fue la falta de sometimiento al mismo, (53,33%), y a su vez esta se debió en su mayor porcentaje al olvido y a los costos de la medicación (44% c/u), siendo pocos los casos de abandono por intolerancia al fármaco empleado.Conclusión: Con lo observado se estableció la necesidad de reducir esta falta de colaboración al tratamiento mediante un seguimiento más persistente e integral de los pacientes hipertensos, el que incluye educación del paciente sobre la importancia y consecuencias a corto, mediano y largo plazo de su enfermedad y los beneficios de la terapia.

Objective: To determine common causes of an inadequate response to the antihypertensive treatment in our environment and how many patients can control their blood pressure with their treatment.Study Design: This is a retro prospective study made in cardiology service of Luis Vernaza Hospital – Guayaquil, where we chose 100 hypertensive patients under treatment and tried to determine its efficacy. We chose those who were not controlling their pressure and tried to establish more common causes of their inadequate response to the treatment. Results: Approximately 60% of patients had an effective control of their blood pressure. In those who were not under control we found that the outstanding cause of an inadequate response to the treatment was the lack of adherence (53.33%) and at the same time this lack of adherence to the treatment was due to forgetting as much as medication expenses (44%) and there with few cases of withdrawal for intolerance to the drugConclusion: As we observed, it is necessary to reduce this lack of adherence to the treatment by means of a more aggressive and integral following of hypertensive patients, which should include education of the patient about the importance and short-term and long-term consequences and also the benefits of the treatment.